Form I - PA Verification of Licensure Form

FORM I

VERIFICATION OF LICENSURE FORM

For Physician Assistant Seeking Licensure in the State of Georgia

Please complete the top section of this form and mail it to all state boards by whom you are/have been

licensed as a Physician Assistant, regardless of the status of your license in that state. You may copy

or download as many copies of this form as needed.

I am applying for licensure as a Physician Assistant with the Georgia Composite Medical Board. The

GCMB requires that this form be completed in order for the undersigned to be considered for licensure

in Georgia. By signing this form I give my consent to release any information, favorable or otherwise,

for its review, in considering my application for a physician assistant license. Please forward to the

Georgia Composite Medical Board as soon as possible.

License Number ________________ was issued by your State Board on

Examination

Other

Signature

Print or Type Full Name

Address

City

State

Zip Code

THIS SECTION TO BE COMPLETED BY ENDORSING STATE BOARD

Physician Assistant License/Certificate Number ___________________to practice as a

Physician Assistant in the State of ____________________________ was issued to

on

(Name of License Holder)

(Date Issued)

Has any disciplinary action ever been taken against the above Physician Assistant including but not

limited to suspension or revocation? _____Yes _____ No. If yes, please furnish details (use additional

page if necessary).

Signed: ________________________________

Title:______________________________

Date: __________________________________

State Board Name:__________________

(Board Seal)

RETURN FORM TO:

GEORGIA COMPOSITE MEDICAL BOARD

Attention: Physician Assistant Unit

2 Peachtree Street, N.W., 36th Floor

Atlanta, Georgia 30303

Form I - Physician Assistant ¨C Verification of Licensure Form

Revised: 12/2009

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